Your study found that high exercise adherence was associated with better outcomes but moderate adherence did not provide a significant advantage over low adherence. Why do you think that is and what implications does this have for clinical practice? 

This was a somewhat unexpected finding but there could be a few reasons for it. 

First, there is not a clear dose-response effect of exercise on pain and disability, meaning increased adherence to exercise may not necessarily lead to better outcomes. 

Second, pain is influenced by a range of biopsychosocial factors and is highly individual and complex. 

Focusing too heavily on exercise adherence risks overlooking some of these factors, which may play a significant role in shaping a person’s pain experience. 

Clinicians should be mindful of this. 

Many of the included trials measured adherence based on session attendance rather than actual exercise completion. How might this limitation affect the interpretation of your findings and how could future research improve adherence measurement? 

This was a key limitation of most of the trials included in our review. 

Attending an exercise class and completing the exercises as intended can be very different things. 

The fact that so many trials in our review used session attendance as a proxy for exercise adherence should make readers more wary of the findings. 

Future research could improve adherence measures by using more detailed data collection methods such as written training logs or objective data from wearables like smart watches. 

Dr Matthew Jones is an exercise physiologist and researcher at the University of New South Wales.

Given that the overall differences in pain intensity and functional limitations between high and low adherence groups were small, should clinicians focus more on increasing adherence or other aspects of exercise prescription, such as individualisation or patient engagement? 

The average rate of adherence in the high, moderate and low adherence subgroups was 90 per cent, 70 per cent and 35 per cent, respectively. 

Despite these differences in adherence, variations in pain and disability between the adherence subgroups were small (usually less than five out of 100). 

This would suggest that clinicians do not need to focus too heavily on maximising exercise adherence in their clients to improve their pain and disability. 

However, increased exercise adherence would likely be associated with additional health benefits, so this may be a reason for clinicians to prioritise individualisation and client engagement to maximise adherence. 

Your study highlights the need for better reporting of exercise adherence in clinical trials. What specific recommendations would you give to researchers designing future interventions for chronic non-specific low back pain? 

Reporting of exercise interventions, not just adherence, is notoriously poor in clinical trials. 

This can limit translation of findings from research to practice; clinicians cannot replicate interventions if the details are not documented adequately. 

Researchers should use established reporting guidelines such as the Consensus on Exercise Reporting Template or the Template for Intervention Description and Replication, which outline how to report interventions in full, including adherence/fidelity to the intervention(s). 

These templates offer prompts such as, ‘If intervention adherence or fidelity was assessed, describe the extent to which the intervention was delivered as planned.’ 

What are the next steps in research on exercise adherence and low back pain? Are there particular strategies or interventions that you think could effectively improve adherence in clinical settings? 

In our review, we suggested a few possible future research directions. 

One suggestion is to investigate whether the associations between exercise adherence, pain and disability observed immediately post-treatment persist at medium- and long-term follow-up. 

Additionally, different research methodologies such as individual participant data meta-analysis or adjusted per-protocol analysis could give us a better idea of the causal effect of exercise adherence on pain and disability. 

These methods would be less prone to ‘healthy user bias’, which may have influenced our results. 

We did not investigate strategies that improved exercise adherence but previous research in this area shows that education, goal setting, self-monitoring and personal feedback are effective. 

>>Dr Matthew Jones is an accredited exercise physiologist and senior lecturer in the School of Health Sciences at the University of New South Wales, Sydney. His research focuses on the role of physical activity and exercise for the management of chronic pain and associated comorbidities. 

Click here to read the paper. 

Course of interest:

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